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Broome Docs is Moving address

Filed Under: Uncategorized by Casey Parker — 1 Comment
June 4, 2012

In order to find a more secure and long term home on the wide wide Web I have decided to change servers and get myself a new domain.  Big thanks to Dr Mike Cadogan from LITFL for dragging my technical ass into the new world and making all this possible!

Don’t worry this is just a technical change – the same material will continue to flow – just from a new address – so go get a pen and write this down….

actually just click on the address, open the new site and add it to your favourites!

If you have been using a reader or accumulator to follow Broome Docs than you will need to add the new address / RSS feed to your service.

OK – here is the address:   broomedocs.com

I know, what it should have been all along, but it is a long story…

This old site will not be updated after next week – see you on the other side!

Casey

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Clinical Case 054: Just a sip

Filed Under: Clinical Cases, Emergency, General Practice, Paediatrics by Casey Parker — 2 Comments
May 27, 2012

Mother of a 15 month old boy (weighs 11 kg) presents to the clinic with a bottle of massage liniment.

 

A quick glance at the label tells you the active ingredients are;

 

Per 50 milliliter:

 

 

Mum says she just popped out to hang the washing and left him playing on the floor.  She was not aware that her teenage son had left the bottle on the couch after going to footy practice.

 

When she came back inside she immediately smelled the menthol and found the little guy on the floor, playing with the bottle, it was dripping down his chin and he was making a disgusted face – like he had a bad taste in his mouth.  She picked him up and could smell the scent on his breath.  But he was fine, happy and she gave hi a bottle of milk to settle him and get the taste out of his mouth.
Ok, now you are seeing him 45 minutes later – he still looks fine, he is playing happily, smells like a gymnasium.  His obs are all normal and Mum says:
“I am sure it is fine – but I just thought I should bring him in for a quick once over…”
After examining him you agree that he is normal, no signs of respiratory distress, no chest or abdo signs.  Now here are the questions:
Q1:  What is likelihood that a toddler would have swallowed more than a few mils?
Q2: Which of the ingredients are potentially toxic? And how much would be required for potential serious badness?
Q3:  What signs, symptoms and timeframe will you want to keep an eye on this little boy?
Q4:  What resources can you use to help make this assessment and formulate a management plan?


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PHARM: Dr Minh Le Cong’s blog

Filed Under: General Practice, Specialist Tips, Uncategorized by Casey Parker — Leave a comment
May 24, 2012

Dr Minh Le Cong has finally found his own home and settled down with a nice new blog called Prehospital and retrieval medicine PHARM.

This is a high quality blog looking at all things to do with transfer and prehospital care of the sick patients in remote parts of Australia.

Minh is mildly obsessed with all things airway, psychiatry and critical care.  My type of guy!

If you are interested in this stuff then go to the site prehospitalmed.com

FYI there is a discussion podcast between Minh, myself and Dr Tim of the KI-Docs blog about all things to do with remote care, education and training.

Check it out.

Casey

Twitt
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Clinical Case 053: thoracic tortuosity

Filed Under: Clinical Cases, Emergency, General Practice, Internal Medicine by Casey Parker — 6 Comments
May 17, 2012

OK.  This is just plain out there.  We see some unusual stuff in the remote areas – things you only read about in the books!  I am going to put this in the category of medical voyeurism.  This is not how we should go about our business, but I had to share these pics!

20 yo with pleuritic chest pain, not much else, but hypertensive BP =  160/90 [not that unusual up here in the tropics]

He managed to get a D-dimer… and then the inevitable CT angiogram  (probably PERC negative)

Here is a slice from the CT -

OK – spot diagnosis, what is going on?

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Clinical Case 052: Belly, bum and balls…

Filed Under: Clinical Cases, Emergency, General Practice, Paediatrics, Surgery by Casey Parker — 7 Comments
May 14, 2012

Today’s case is not in the ED.  This one unfolds on the ward – the morning after the admission.  So imagine yourself there – on the Paeds surgical ward.

6 year old boy was admitted last evening after referral from the local GP to the on-call Surg team.

He has a 24 hour history of increasing central abdominal pain.  The pain wa initially periumbilical, but overnight it has localized to the lower abdomen – maybe a bit more on the right. Urinalysis was normal

The surgical team have been on their super-early orning rounds and seen the child – they have written in the notes:

“ tender lower abdo, no rebound, guarding, otherwise soft, afebrile.  Bloods all normal.  PLAN:  Med team consult please.? epurients”

OK, now that is Surg -speak for – we aren’t operating on this kid – not a likely appendix.  Turf to med, maybe its constipation?

Half way though your ward round the nurse- coordinator calls you to say:  “You had better come see this kid – he has just had a bout of melena”

Hmmmm… not sounding like your average “un-appendix”.  So you pop in and see him.  Mum is looking worried.  His obs are normal, his belly is ‘as described’ by the Surg team.  When you pull down his jocks for a gander at his bottom you notice his scrotum is a bit red, and on examination his left testis is tender and there is a definite hydrocoele.  Hmmmmm…

OK – can you solve this Paediatric puzzle?

What is going on?  Well here is the clincher.

Rash

What are you going to do next?

Congrats to Dr Bek – who as it turns out practices about 500m down the road from me at the local Aboriginal Medical Service.  Bek gave the right and most insightful answer.  Good call from Maj and Patrick also – honorable commendations.  I happen to know Bek was at a recent talk I gave which covered HSP – so technically she did cheat? But I think she already knew before I got to her!

HSP (Henoch-Shonlein purpura) is an IgA-mediated leukocyoclastic vasculitis which produces a syndrome in children as described by the eponymous gents (and Heberden 30 years earlier). They described the quadrad of: purpura, arthralgia, abdominal pain and melena. Of course, they missed the meat – the renal disease. The disease involves a vasculitis of small vessels in the skin, gut, joints, glomeruli etc. It is pretty much the same disease as IgA nephropahy (Berger’s disease) in adults. HSP ends to occur in young children 4 – 10

I love HSP as a diagnosis as it is one of those end-of-the-bed diagnoses which can present in a number of ways – a rash, joint pain, belly aches etc. You have to keep it in you thoughts or you might miss it. The diagnosis is basically clinical – unless it is unclear as to the cause of the rash – so you might check for other causes of purpura. As opposed to ITP etc the platelets will be normal or elevated.

Treatment is mainly symptomatic – analgesia and “surgical” management of complications such as intussusception or torsion. GI bleeding, abdo pain and joint pain are usually treated with oral steroids. Does it work?  Well – maybe.  There are papers in both direction but they are all small and lack the power to say yes or no.  A rough summary is that they might make you belly pain get better sooner,  make the likelihood of an operation or CT scan lower and just might improve joint symptoms.  Now onto the million dollar question… the beans.

The reason HSP is an important problem in the long term is that there is an incidence of chronic renal disease. Usually a nephritic syndrome (though some mixed or nephrotic). And some of these kids will progress to renal failure. Here is the problem – there are studies that show that early steroids, and even cyclophosphamide do not reduce this progression. So we cannot treat the serious complication.

Monitoring includes urinalysis testing, BP monitoring – as there is about a 7% recurrence rate and the risk of renal disease goes up with recurrence and older-age of the kid.

 

Twitt
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Ultrasound for Epidurals… I ask an expert: Dr Mitch

Filed Under: Anaesthetics, Obstetrics, Specialist Tips by Casey Parker — 5 Comments
May 10, 2012

I have had a few readers ask questions about the use of ultrasound for the difficult epidural – usually in the labour ward context, but we sometimes run into this in the OT for combined spinal-epidural blocks.  Now I  love all things ultrasound – but looking at the literature it is tough to get a read on the utility of US in the often troublesome area of epidurals.  All those bones – can we see anything useful?  So I have asked an expert, and gotten a few handy, practical pointers.

Dr Chris Mitchell is a Consultant Anaesthestist at King Edward  Memorial Hospital for Women in Perth, Western Australia. But Mitch is more than an Anaesthetist – before he went into specialist training Chris was a rural GP-Anaesthetist in NW WA.  In fact my first job after my training in Anaesthesia I actually replaced Chris!

Now onto the meat of the post – here are Chris’s tips in beautifully illustrated form – click here [US for Epidurals]

I think it should be said – epidurals in the labour ward are an elective procedure.  There is a risk : benefit pay off.  If you are increasing the risk side of the equation as a result of a difficult insertion, then you need to discuss that with the patient – so before calling for he US machine I think it is worth a pause to consider if this is worth a try – I am sure that for the occasional operator this technique wil help, but is no magic bullet!

We usually try and avoid the patients with really tough anatomy – if the BMI is over 35 we usually start to strongly consider referral to a larger institution for a whole raft of safety reasons.

Huge thanks to Dr Mitch for his pearls on epidurals and US.  I would love to hear your experiences and if you have any questions for Chris I will pass them along.  Comments please

Casey

 

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Clinical Case 051: Cardiac conundrum

Filed Under: Emergency, Internal Medicine by Casey Parker — 11 Comments
May 6, 2012

This week’s case is “chest pain” in a relatively young man.

I am going to make it tricky by giving you info bit by bit – see if you smart buggers can work it out.

Step 1 – here is the initial ECG.  2 hours of central chest pain.  What is happening?  what are you going to do?

Does he meet criteria for thrombolysis?

OK – so you all seem to agree he has pericarditis on the ECG.  And the history was convincing – 23 yo, pleuritic left chest pain, radiating to the left arm.  He had a story of an acute “strept throat” and was just finished a week of oral penicillin.  BUT – the initial tropT was 0.88, and in the morning it was up to 16!  So he clearly has more than a simple pericarditis.

Just to be sure, late at night I did a bedside ECHO to check if he had anything suspicious.  This showed a small pericardial effusion and no “eyeball” evidence of regional (inferior) wall motion abnormality (for what it is worth with me – an ECHO gumby looking with my eyeballs!)

So lets say he has a myopericarditis.  Let us now look at the treatment.  How do you manage this?  And if you are super-smart – are there any other causes to consider other than “viral”?

If you are unaware of Dr Smith’s ECG blog then check out the section on pericarditis here - lots of pearls for telling MI from pericaritis.

Let me know on he comments.

Twitt
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Medical Myths: Fever = blood cultures now!

Filed Under: Emergency, Internal Medicine, Useful Evidence by Casey Parker — 6 Comments
May 1, 2012

When I was an intern in a big old hospital one of the tasks we did was taking blood cultures off of patients who spiked fevers on the wards.  In fact thinking back on it, I think I was taking cultures to appease the senior ward nurses and not really stopping to think about the why?  Probably stabbed any number of patients with early sepsis and happily continued onto the next job without even worrying about the BP, lactate, line sepsis etc etc…  It was an annoying task as it was “time critical” – you had to get the cultures ASAP as the fever spiked – or else the boss would be grumpy, we might “miss the sepsis”.

Were we right to worry about getting the cultures done in a timely fashion?  Did it have to be “during the rigors?”

My colleague pointed out this paper by Riedel et al, Journ Clinical MIcro (April 2008).  This case-review looked at 1436 patients and their fever – culture timing profile and found that it really didn’t matter when you took the cultures in realtion to the spike of a fever – the majority of positive came from cultures taken hours after a fever.  This study cannot comment on the numbers of “missed” bacteremias as a result of wrong / delayed timing.

So what does it all mean for you, next time the nurse calls to tell you Mr Jones has spiked a temp….

  1. Walk, don’t run – it really doesn’t matter if you do it now or in an hour.
  2. Go there, look at the patient and think “what is going on here?”  Does he have a reason to be febrile already documented, on appropriate therapy?  Or, is he someone who needs to be reassessed for sepsis – does he have a line infection?  Does he have a wound infection?  Is he in SIRS or worse?  Do you need other sites cultured – urine, chest etc?
  3. Take cultures as clean as possible – aseptic approach – try and avoid those frustrating false positive BCs
  4. Contemplate changing the plan – look at the AB cover – is is sensible? Do you need to yank a line or call a surgeon to drain some pus?

Thanks Ben for the article.  Interns – relax, but do a more thorough job!    Casey

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Clinical Case 050: Think Better, Do Better

Filed Under: Clinical Cases, Emergency, General Practice, Pearls and Pitfalls by Casey Parker — 5 Comments
April 30, 2012

Last week I received the following comment from a reader in a country nearby.  This was a great story for me to hear as it made all my long hours of reading and writing seem worthwhile.  There are plenty of podcasts and blogs that will teach you how to do life-saving stuff – but this story is about how a reader took something from Broome Docs and ‘saved a life’ in a very different way.  It is not about a single trick or a procedure – but about how to approach the daily practice of medicine in a better, patient-oriented and effective manner.  For me this is the essence of why I do what I do at Broome Docs.  Here is the story from Dr Tom:

Hi Casey,

Straight after I read your first article on Consult Skills, I clipped and saved it using Evernote so that I could access it on my iPhone whenever needed.

Lo and behold, last week I had my first opportunity to use it when a middle–aged lady presented with a two year history of severe low back pain, bilateral hip pain and right leg pain. She had had multiple visits to her GP, several locums and 3 different orthopedic specialists over that time. Even though she was on a benefit, she had paid to see a couple of specialists privately because she was so desperate.

When she arrived in our ED, one of our relatively new Resident Medical Officer’s went to see her. The RMO came back very frustrated and said that both the patient and accompanying relatives were very angry and demanding, and that she wasn’t really able to get anywhere with her.

At that stage I said to the RMO that we had two important functions to fulfill:

1.      To make sure that the patient didn’t have any emergent orthopedic conditions e.g. cauda equina syndrome, spinal abscess etc.

2.      To try to understand the patient’s point of view.

The latter was met with a slightly quizzical expression so I pulled out my iPhone, opened my Evernote application and showed her the section I had clipped a few weeks ago:

1.      They want to know the doctor is listening to them

2.      They want to know that the doctor cares

3.      They want to make sure the doctor understands what is going on

4.      They want the Doc to “get it right” – that is make the right call / decision / do the right test  etc…

5.      They want to know what to do next “what will happen to me now?”

At that stage I went into the patient’s room and said:

‘Hi, my name is Tom – I am the senior ED doctor on duty today. I understand you have been going through a really rough patch lately. The first thing I am going to do is to take your pain way with some morphine. Once you are comfortable, I would like you to tell me everything that has happened to you over the last couple of years; then I will have a good look at you, review your results, talk to the orthopedic specialist on call today and together, we will try and come up with a plan to get things sorted for you.

After 10mg of morphine she said – ‘Doctor, you know this is the 1st time in over two years that I have not been in pain’.

She then proceeded to tell me:

•       Her marriage had broken up and she was looking after 6 children on her own.

•       She was in so much pain that she was unable to dress herself (mainly because she could not bend down or stand on one leg), was unable to walk more than a few steps, had hardly been out of her house in the past few weeks and was largely confined to her bed or a chair.

•       She had a history of multiple severe drug reactions and was not currently taking any analgesics.

•       She suffered from stress incontinence and wet herself at least 2-3 times every day.

•       When she fell over, she was physically unable to get off the floor unaided.

•       Her teenage son had to take time off school to help dress and wash her, clean the house and do the cooking – this was now starting to adversely affect both his education and their relationship.

•       She was not eligible for any government subsidies (e.g. home help).

•       She was often tearful due to a combination of pain and frustration.

After listening to her history, I briefly re-capped to make sure that I had not missed any important points.  I then examined her and reviewed her recent imaging.

Next I rang the on-call Orthopedic Specialist and said –  ‘I’ve got a lady with chronic severe lower back, hip and leg pain; a plain film of her pelvis and hips shows severe bilateral hip OA; she doesn’t appear to have any new emergent orthopedic conditions but I would like to admit her so that we can sort out her analgesia, home help, mobility and definitive treatment’.

I returned to the patient and told her: ‘Great news, the Orthopaedic Surgeon has agreed to bring you into hospital, sort out your pain, get you a bit more mobile and most importantly, try and fast track some surgery on your hips.’

At that point she started crying and said:

‘You know, of all the doctors I have seen over the last few years, you are the only one who has ever sat down and really listened to what has been going on. Thank you so much’.

PROGRESS REPORT

After initially being admitted to hospital for a week, she has gone on to have her 1st hip replacement done and is due for her 2nd operation in 3 months time.

Great work Dr Tom.  I really appreciate your sharing this story with me and knowing that we can do better by changing the way we think and talk to patients.

Twitt
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Broome Docs in the Fast Lane

Filed Under: Uncategorized by Casey Parker — 3 Comments
April 27, 2012

Apologies to the regular readers (and the slightly odd ones too!).  It has been a slow week for updates at Broome Docs as I have been in the big smoke (Perth) doing a bit of a refresher in all things Crit Care in SCGH - and catching up with the Life In the Fast Lane crew at the same time.  It has been a discovery tour where I have had the chance to practice a few skills, ask a lot of difficult (?stupid) questions and learn a thing or two about what it is we do!

Met Dr Mike Cadogan (@sandnsurf) today and I can say it was a “blog changing” experience!   I recorded a chat with Mike for his upcoming podcast and learned stuff about blogging, education, life etc that I didn’t know I didn’t know!  Left Mike’s office with the feeling I was thinking in slow-motion!  I hope to be making my own contribution to his upcoming iMeducate program, providing cases / fodder in this intriguing project which will change the way we access our education and learning at all levels.

If you want to hear me going on about the whole interweb thingy with the master then click here for the 9 minutes of CITFL chat we recorded in his tiny, but very busy office

Anyway – I’ll be back in sunny Broome next week and hope to bring you a whole heap of new stuff, cases and evidence that I have garnered over the last week!

Casey

 

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